Running head: COMMUNITY HEALTH PROMOTION 1

Community Health Promotion in Pediatric Home Health Care

Delaware Technical Community College - Stanton Campus

NUR 330 Population & Community Health

Megan Couden

November 23, 2019

Community Health Promotion in Pediatric Home Health Care

Home health care is a division of nursing that provides skilled nursing care in the client’s

home. Through home health agencies, field nurses create a plan of care for the clients with the

input of the entire multidisciplinary team in order to meet the holistic needs of the client while

allowing them to remain in the comforts of their own homes. Medications, treatments, and

equipment are setup and administered as needed for each specific client. Safety, environmental,

and psychosocial needs are assessed and managed. Therapies, special treatments, and home

health aides are also available so the client is able to live to their fullest potential. Medicare

describes home health care as “unique” in that the client receives skilled medical care at home

that is just as effective but often less costly and more convenient for the client (Alliance for

Home Health Quality and Innovation, 2019).

Home Health care Population

The population within the home health care field in this assessment focuses on pediatric

medically complex clients. Pediatric home health care includes children from newborn to 18

years old. Adult clients who have been with the home health agency since they were young and

have developed a rapport between nurses and families may elect to stay on with their pediatric

home health agency through a track program. Adjustments are made with Medicare coverage and

insurance carriers accordingly by changing from Health Options or Amerihealth Medicaid plans

to the adult Managed Medicaid Health Options plan. Challenges when children become adults

arise as it becomes more challenging to obtain coverage for necessary equipment and supplies

for the adult population than it is for children (T. Pariag, personal communication, October 7,
COMMUNITY HEALTH PROMOTION 3

2019). All cultures and ethnicities are served with a variety of languages spoken in homes. With

the diverse client base, there is a wide spectrum of resources and barriers in this population

depending on the socioeconomic status of the family. One client may live in a six bedroom home

equipped with a fully functional overhead lift and elevator to reach the second floor, while

another client may live in a third floor walkup apartment with limited parking. It is up to the

home care nurse to assess the environment and work with the multidisciplinary team to identify

any potential barriers to safe and effective care and help find appropriate resources to meet the

needs. If the safety of the nurse is a major concern, the nursing agency may determine not to take

on the case.

Healthy People 2020 identifies access to health care, health care associated infections,

and immunization and infectious diseases among their topics and objectives of concern in health

care (Office of Disease Prevention and Health Promotion, 2019). These three objectives out of

the many identified have the greatest impact on pediatric home health care in which barriers and

concerns can be focused in order to improve quality of care. Home health care agencies are

regulated by internal Quality Assurance teams who audit nursing and agency performance in

order to ensure company policies are being followed and that client care is consistent with

physicians’ orders (T. Pariag, personal communication, October 7, 2019).

The nurse’s role in home health care lies both in the field as a hands on nurse, providing

direct client care on a shift-by-shift basis, and in the office as a clinical manager, overseeing

multiple client care plans, coordinating changes with the multidisciplinary team as needed,

performing periodic physical assessments to ensure needs are continuing to be met, and

communicating with field nurses regarding client status. The presence of home health care

nursing allows primary caregivers to work, sleep, and have respite from the continuous needs of
COMMUNITY HEALTH PROMOTION 4

their medically complex child or children. Disease management and preventive measures that are

used include infection control methods with standard precautions and aseptic technique as

needed. PPE, hand soap, client specific stethoscope and thermometers, hand soap, hand

sanitizing gel, and paper towels are supplied to families. Specialized bag techniques are used by

visiting nurses to ensure that outside agents are not transferred between clients. Safety and

infection control are notable priorities as most medically complex children are

immunocompromised and the smallest illness can lead to a hospitalization. Nurses must follow

the care plan and physician orders, constantly monitor and identify changes in status, ensure

supplies and equipment are available in the home, and maintain open lines of communications

with clinical managers and physicians ensuring client needs are met and kept up to date (T.

Pariag, personal communication, October 7, 2019).

Identified Needs for Health Improvement and Potential Barriers

Aligning with the Healthy People 2020 objectives pertaining to pediatric home health

care as well as observations through studying the population within a home health care agency,

three specific needs can be identified. Infection control must be maintained especially during

RSV/cold/flu season. Health care related infections must be prevented, particularly when

performing skilled medical procedures and those requiring aseptic technique in the home setting.

Access to health care services must be addressed at the onset of care and remain ongoing as the

needs of the child change. Finally, communication must be kept open between all members of

the multidisciplinary team including time spent educating clients and caregivers to ensure

understanding and compliance of care when nursing is not available in the home.

Infection control begins with availability of supplies in the homes to prevent the spread of

infection. Gloves, masks, goggles, gowns, hand soap and sanitizing gel, paper towels, and
COMMUNITY HEALTH PROMOTION 5

sanitizing wipes for equipment must be available and within reach. Health care associated

infections during sterile procedures poses more risk to clients in the event of limited supplies.

Breaking the chain of infection puts clients at risk. Bringing nursing supplies that are used with

multiple clients also put clients at risk if not following proper bag technique or failing to clean

equipment. Families may also carry germs and pose risks to clients on a daily basis, especially

during fall and winter months when germs are more prone to spread (Burke, 2019).

Access to health care services means insurance coverage should correlate with the degree

of care the client needs for optimal outcomes. Durable medical equipment, medications, medical

supplies for medication administration and treatments must be coordinated and available in the

home and re-supplied routinely. Safety and environmental concerns may pose challenges to

receiving access to home nursing care and therapies. Families and caregivers may use supplies

intended for the nurses and client resulting in more frequent depletion (T. Pariag, personal

communication, October 7, 2019).

Breakdowns in communication as the different physicians, nurses, therapists, and other

members of the multidisciplinary team revolve in and out of the client’s home making changes to

the plan of care poses challenges to client status and outcomes. Medicare regulates that the plan

of care must be reviewed and updated every 60 days (Centers for Medicare and Medicaid

Services, n.d.b). Changes often occur more frequently, requiring constant updates as needed to

the plan of care through addendums which must be communicated accordingly to all nurses,

therapists, and other members of the multidisciplinary team rendering care (T. Pariag, personal

communication, October 7, 2019).

SMART Goals and Interventions

Infection control can be addressed with two separate goals, one in the area of supplies

and the other in nursing technique. All necessary supplies should be identified and available in

the home from the onset of care and maintained through the duration of care. To ensure there are

enough supplies maintained in the homes, an initial assessment should be done to determine

which client specific supplies are needed to provide safe, comprehensive care. The inventory of

items, the amount needed to sustain a 60 day period, how often disposable supplies must be

replaced, an accurate shift count documented weekly on the spreadsheet to ensure adequate

supplies are available, and whether supplies are covered by insurance, the DME, the home health

care agency, or the family all should be organized into a spreadsheet. This spreadsheet can

portray the accuracy of supply needs and allow changes to be made as needed.

The goal for providing safe skilled nursing procedures in the home is to complete all

procedures utilizing proper precautions, performing skills safely and accurately, without error or

contamination of the client. Proper bag technique should be maintained and all shared equipment

cleaned sufficiently to prevent transmission of infective agents between clients. Skilled nursing

techniques should be tested for performance competency prior to providing client care and

assessed by a clinical manager or experienced nurse preceptor in the field during the initial

treatment by the nurse. This allows adequate preparation and guidance preparing the supplies

needed, arranging the appropriate environment for the treatment to be provided, and offers a

sounding board for any questions that might arise during the procedure.

Access to healthcare services including equipment, medications, skilled nursing care,

therapies, and appropriate safety and environmental precautions are in place as needed for the

clients to receive the necessary home health care. The home health agency initially assesses
COMMUNITY HEALTH PROMOTION 7

client needs prior to the onset of care, identifies all needs, and determines what is covered by

Medicare, Medicaid, private insurance, the home health agency, or is an out of pocket expense.

Questions about Medicare coverage can be directed to 1-800-MEDICARE (1-800-633-4227).

Children’s Medicaid coverage and CHIP (Children’s Health Insurance Program) can be accessed

at the state level. “Mandatory benefits include inpatient and outpatient hospital services,

physician services, laboratory and x-ray services, and home health services, among others.

Optional benefits include services including prescription drugs, case management, physical

therapy, and occupational therapy” (Centers for Medicare & Medicaid Services, n.d.a, para. 2).

The United Way offers a support hotline by dialing 2-1-1 or accessing 211.org online to help

people obtain quality, affordable healthcare through a variety of programs including Obamacare,

Medicare, Medicaid, children’s health, nutrition, prescriptions, wellness programs, mental health,

transportation, and child care services (United Way Worldwide, 2019). Open communication

between the home health agency regarding medical coverage should be maintained continuously

throughout the contract of care between the agency and the client to ensure proper coverage is

available so the client has consistent care to meet needs. Breaks in coverage should be assessed

quickly should changes arise so that coordination of care can be managed by the

multidisciplinary team. The proper support and identification of client diagnoses could mean the

difference between services being covered or not (T. Pariag, personal communication, October 7,

2019).

Communication within the established home health care agency chain of command and

throughout the entire multidisciplinary team is essential for optimal client care. Deviations from

client baseline status during night shift should be prepared for and a plan put in place for who to

contact and at what point the safety of the client requires more extensive care than what the
COMMUNITY HEALTH PROMOTION 8

home health nurse can safely provide. Maintaining updated records of treatment changes in real

time ensures the most up to date client information is available to nurses providing direct care. A

computer based client portal and paper chart in the home should be kept in a central location

available to nurses that includes organized and current reports from all members of the health

care team. Establishing a positive rapport between the home health agency and the physician

enhances ease of access and prevents communication breakdown through more personal

interactions that benefit the client (Holly, 2018).

Evaluation Plan

The home health agency should conduct a client by client review of supplies available,

re-assess how often supplies are needing to be replenished for accuracy, and make adjustments

as needed to maintain adequate supply. Comparisons with like clients can help determine

consistency and investigations should be conducted in the case of increased use of supplies to

find what may be causing faster depletion. Field nurses can be given a supply kit to be stored in

their vehicles in the case of emergencies which can be rotated into homes to keep stock

fresh/non-expired.

Performance of skilled nursing competencies should be assessed annually and as needed.

Clients and families should be interviewed for any concerns related to nursing skills provided.

Home health agencies should monitor and document all events where complications occurred

during or following skilled nursing procedures, including illness or infection. Nurses should be

interviewed and incidents analyzed on where breakdowns occurred, potential causes identified,

what can be changed, and strategies to prevent future occurrence. Collaboration between

professionals can address and reduce adverse events in the home (Schildmeijer, K., Unbeck, M.,

Ekstedt, M., Lindblad, & M., Nilsson, L, 2018).

The home health agency should maintain open communication with clients and primary

caregivers to ensure all needs and coverages are met, offering support and resources as needed.

Clients with continuing unmet needs should be evaluated and communications pursued with the

physician and multidisciplinary team to work together in an effort to meet those needs in

conjunction with available resources and insurance providers.

Communications between the multidisciplinary team should be consistent and ongoing.

The home health agency should conduct interviews with field nurses, clients and caregivers, to

identify any breaks in communication, assess where the communication gap rests, and establish a

solution that benefits all parties.

Home health care is a growing trend that allows people who have chronic illnesses the

ability to spend their time in the comforts of their home rather than in a medical treatment

facility. Through home health agencies, home bound client care can be coordinated and

maintained successfully with the development of a comprehensive care plan. Skilled nursing care

can be provided in the home just as in the hospital as long as resources are available and that

nurses are trained and follow proper protocol and maintain proper precautions. Successful care in

the home is reliant on open communication among all involved to ensure that the client receives

all necessary care, with resources available and accessible, in order to have the best possible

outcome.
COMMUNITY HEALTH PROMOTION 10

References

Alliance for Home Health Quality and Innovation. (2019). What is home health care? Retrieved

from https://www.ahhqi.org/home-health/what-is

Burke, A. (2019, September 21). Standard precautions, transmission based, surgical asepsis:

NCLEX-RN. Retrieved from https://www.registerednursing.org/nclex/standard-

precautions-transmission-based-surgical-asepsis/

Centers for Medicare & Medicaid Services. (n.d.a). Benefits. Retrieved from the Medicaid.gov

website: https://www.medicaid.gov/medicaid/benefits/index.html

Centers for Medicare and Medicaid Services. (n.d.b). Medicare and home health care. Retrieved

from https://www.medicare.gov/sites/default/files/2018-07/10969-medicare-and-home-

health-care.pdf

Office of Disease Prevention and Health Promotion. (2019, November 21). 2020 topics and

objectives. Retrieved from Healthy People 2020 website:

https://www.healthypeople.gov/2020/topics-objectives

Holly, R. (2018, June 20). Poor communication between home health, Doctors leaves patients

lost in the wilderness. Home Health Care News. Retrieved from

https://homehealthcarenews.com/2018/06/poor-communication-between-home-health-

doctors-leaves-patients-lost-in-the-wilderness/

Schildmeijer, K., Unbeck, M., Ekstedt, M., Lindblad, & M., Nilsson, L. (2018, January 3).
COMMUNITY HEALTH PROMOTION 11

Adverse events in patients in home healthcare: A retrospective record review using

trigger tool methodology. BMJ Open, 8(1). Retrieved from doi:10.1136/bmjopen-2017-

019267

United Way Worldwide. (2019) Health. Retrieved from http://www.211.org/services/health